STATE OF NORTH CAROLINA File No. __________________ COUNTY OF __________________ IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION Plaintiff AFFIDAVIT OF FINANCIAL STANDING vs. OF PARTY FROM WHOM SUPPORT IS SOUGHT Defendant The undersigned affiant, having been first duly sworn as to the truthfulness and completeness of this Affidavit, deposes and says: 1. That I have monthly and/or weekly income from the following sources and none other: (Both columns are to be computed.) * WEEKLY (Prorate if paid SOURCE OF INCOME * MONTHLY monthly or semimonthly Gross wages Deductions: State withholding Federal withholding Social Security Retirement Loans Other (itemize) _________________________________ _________________________________ _________________________________ Net wages Business Profit Commissions Overtime Interest Dividends Trust Fund Social Security Pension/Retirement Rent Bonuses Medical Reimbursements * Round off to nearest dollar. District 1 Page 1 of 6 FDCVD-4 Affidavit of Financial Standing of Party from Whom Support is Sought >>>> 2 * WEEKLY (Prorate if paid SOURCE OF INCOME * MONTHLY monthly or semimonthly Travel Expense Reimbursement Gifts Other (itemize) ________________________________ ________________________________ ________________________________ TOTAL INCOME 2. That I have other assets as follows: IRA Account Yes No Stocks Yes No Bonds Yes No Savings Accounts Yes No Certificates of Deposit Yes No Real Estate Yes No Vehicles Yes No Boats Yes No (If answer is yes, list separately and specifically on a separate sheet to be attached.) 3. (a) Have you remarried? Yes No (b) Is your present spouse (spouse now living Yes No with) employed? (c) If employed, what is such spouses net monthly income? $ (d) Does this spouse receive support from a Yes No former spouse? (e) If so, how much per month for herself/himself? $ (f) How much per month for child(ren)? $ 4. That my pay period is: Weekly Twice Monthly Every other week Monthly Other (Explain) 5. That my total gross income from all sources for the previous calendar year was: $ _______________________ * Round off to nearest dollar. District 1 Page 2 of 6 FDCVD-4 Affidavit of Financial Standing of Party from Whom Support is Sought >>>> 36. That for tax purposes I claim _________ exemptions on my W-2 form (including myself). 7. That I am presently employed with (name of employer) ________________________________ at (place of employment) __________________________________________ , and I have been so employed since (date) ___________________________ . That I was employed with (name of employer) ________________________________________________________ at (place of employment) ______________________________________ prior to where I am now employed. 8. That I do do not have a second job. If yes, that second job is with (name of employer) ___________________________________________________ at (place of employment) ___________________________________________________ , and I have worked there since (date) ______________________ . 9. That I do not have any other income or employment other than as listed in this Affidavit 10. That I have have not received substantially the same income for the past 12 months. If not substantially the same, explain the reason for the change. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 11. That true and accurate copies of all financial statements submitted by me to any lending institution in the past two years are attached to this Affidavit. 12. That since the date of separation from my spouse, I have provided support in the total sum of $ ____________________ for my minor dependent child(ren) living with me. 13. That my own personal monthly financial needs and expenses while living separate and apart form the opposing party are as follows (if all payments are not made by the month, list the average monthly cost for each or pro rata per month over a 12-month period of time): *ADULT CHILDREN *( ) NO. OF AND OTHERS NATURE OF EXPENSE PAID OR MINOR LIVING IN *MONTHLY PAYABLE BY AFFIANT *SELF CHILDREN HOUSEHOLD TOTAL * Round off to nearest dollar. Rent (or house payment) Household maintenance or repairs Household supplies District 1 Page 3 of 6 FDCVD-4 Affidavit of Financial Standing of Party from Whom Support is Sought >>>> 4 *ADULT CHILDREN *( ) NO. OF AND OTHERS NATURE OF EXPENSE PAID OR MINOR LIVING IN *MONTHLY PAYABLE BY AFFIANT *SELF CHILDREN HOUSEHOLD TOTAL * Round off to nearest dollar. Utilities Heating (fuel oil) Water Electricity Telephone Gas for home Automobile payment Automobile maintenance Automobile gasoline Other transportation costs Food at home Food away from home (including school lunches) Clothing (purchase) Personal care (grooming, laundry, dry cleaning, etc.) Extracurricular activities (recreation, entertainment, sports) Medical expenses (including doctors, hospital, dentist, drugs) not paid by insurance Educational expenses (including school supplies, fees, tuition) Reading materials Tobacco and alcohol Club dues and expenses Cable TV Insurance: Hospitalization and medical Automobile Life District 1 Page 4 of 6 FDCVD-4 Affidavit of Financial Standing of Party from Whom Support is Sought >>>> 5 *ADULT CHILDREN *( ) NO. OF AND OTHERS NATURE OF EXPENSE PAID OR MINOR LIVING IN *MONTHLY PAYABLE BY AFFIANT *SELF CHILDRE N HOUSEHOLD TOTAL * Round off to nearest dollar. Other (itemize) _______________________ _______________________ _______________________ Church pledge (including Sunday School) Gifts $ TOTAL MONTHLY (Children et al column).......................... **TOTAL BALANCE DUE (DEBTS) Debt payment MasterCard VISA Checkloan Credit Union Reserve Other (Finance companies, banks, department stores) ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ TOTAL MONTHLY (Self) ........................................................................ $ TOTAL MONTHLY (Minor Child(ren) ..................................................... $ (A total for adult children et al column is not required.) TOTAL BALANCE DUE (Debts) ..